Basic Information
| Provider Information | |||||||||
| NPI: | 1376557454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055676611 | ||||||||
| FaxNumber: | 3055760008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 FEDERAL HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331373795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055676611 | ||||||||
| FaxNumber: | 3055760008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 11/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME68684 | FL | N | Other Service Providers | Specialist | 2084P0805X | ME68684 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | ME68684 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 27701S | 01 | FL | MEDICARE | OTHER | 379235800 | 05 | FL | MEDICAID |